Ask Dr J – Issue 173 – Burning joints at the Alter of Hedonism

By Dr Julian Saunders

BURNING JOINTS AT THE ALTAR OF HEDONISM

I’ve had an inflamed middle knuckle in one of my fingers for a few months. I saw a doctor, and after an x-ray he told me it was synovitis, the first stage of rheumatoid arthritis. He told me a) not to be worried and b) maybe to be a little worried. I’m 25 and hope to have a long climbing life ahead of me. Aside from four weeks of rest and a steady dose of anti-inflammatory drugs, what else is recommended? Is there an effective physical therapy for your finger joints? I’ve done physical therapy twice, which just consists of dipping my hand in hot wax a few times and then resting it under a heat lamp. He also advised me to soak it in hot water at home.

Bedhead Rock and Ice Forum

Arthritis is the silver bullet that every hedonist climber wants to avoid. The young are invincible if only in their own angst-driven world; the old have arthritis already and are dealing (or not), but the middle-aged hedonist is frightened like a baby fur seal.

Inflammation of the synovial cartilage (aka hyaline cartilage, the shiny surface on the ends of the bones in synovial joints), can be alarmingly painful. Mostly, it will feel like a slow-burning fire. Squeeze the joint and it will become more like an oxyacetylene torch. Aside from emanating pain on pressure, it will cause a dull pain deep in the joint whenever you run the joint to the end of its range, worse so when it is loaded.

In climbers, the impetus for synovitis (and its conjoined twin, capsulitis) in finger joints is usually the loss of accessory motions, namely rotation and side-bending, by chronic overuse. The joints become stiff and easily aggravated.

X-rays are not illuminating for synovitis or the early stages of rheumatoid arthritis (RA). I assume your doctor has made the diagnosis of synovitis on the basis of joint pain alone, and really, it’s a reasonable call. RA, on the other hand, is a behemoth step along the diagnostic odyssey given your penchant for a retro-evolutionary hobby. Many doctors like to add a little drama into their day by telling you all the things it could be. Puts the wind up you, and gives them an overwhelming sense of omniscience.

Synovitis is a symptom of, among other things, arthritis. The differential diagnosis for synovitis is as wide and varied as an inflamed lymph node in your neck. Yes, synovitis could herald RA, an inflamed node could be leukemia rather than a cold, and a headache could be the mother of all tumors rather than too much time on the Internet. In 80 percent of RA cases, a simple blood test will answer your question.

When the surfaces of a joint are jammed tightly together the synovial cartilage becomes annoyed. When the opposing joint surfaces are able to shift about a little and assume a comfortable position, there is less irritation.
Stretching your fingers is a jolly fine idea. Most climbers tend to think that pushing your fingers back for a few seconds as you take a final glance skyward constitutes a stretching program. Feckless drunks, of course. This type of stretch, aside from being categorically useless, will not actually stretch the joint capsule, which contains and stabilizes the joint.

Take your finger and twist the last two segments like a homebrew screw top. Now bend it sideways as well. Hard! [Go to http://au.youtube.com/ watch?v=IMO__OrzM_U.] It will both feel and look alarming. At first the site will be exquisitely tender, but the days of masochistic bliss will regrettably fade. If you are a city dweller, the inconvenient traffic light is now your friend.

Hot wax, hey? I can think of a few uses for hot wax that would result in more satisfaction. But I don’t want to talk about my private life. Without any adjunctive therapy, you could apply it more times than Linda Lovelace for only marginal benefit. And I fail to see what therapeutic benefit hot wax has over hot water. That said, it won’t do any damage (other than to your wallet), and will surely help the process in conjunction with some targeted stretching.
Anti-inflammatory medication will only band-aid the problem in the short term. In?ammation and pain arise due to an underlying problem, in this case joint overload and tightness. Rest, in this instance, is a bit over-rated. Stretch the joints aggressively and, suffice to say, crimp less.

Pain in your joints is a great bellwether. As you can see from other posts on the forum, this problem has a propensity to return. Deal with it now!

In defense of your doctor, synovitis in the general population is often indicative of some form of arthritis. Synovitis is arguably more common in the fingers of climbers, but is it related to joint stress rather than arthritis.
A word of caution: Stress fractures close to the joint can have a similar appearance. If the pain does not subside, procure yourself some appropriately fancy images.

BIBLE BUMP

I have a retinacular cyst at the MCP joint of my left ring finger. My doc aspirated it but it came back within the same week. My doc wants to do an MRI, which may or may not be followed by surgery depending on the size of the tear in my tendon sheath. He told me he doesn’t think the tear is big, in which case I will be told to rest for four (or more) months! I haven’t climbed since March and I’m going crazy. The cyst is back to its original angry size, and has not diminished with rest. Should I rest it and take up swimming, or is surgery the only way out?

EILY MORAN, ALBUQUERQUE, NEW MEXICO

Well, you are in a spot of bother. Although technically climbing would do very little to the actual cyst in biomechanical terms, pressure on it will usually cause varying amounts of discomfort depending on where it sits. Jugs are, ironically, often worse than smaller holds.

Sucking the guts out of it (aspirating) will typically be a failure. Cortisone is likely to be a close second, though there is a slim chance it would work. Failure rates are thought to be somewhere around 50 percent, though I would say that figure is optimistic.

Surgery is a much better shot, with failure rates around 20 percent. Recovery would also be considerable, though not four months. I would expect more like two months, with your entrance back into the cathedral of climbing to progress thereafter. The good thing is that there is no hurry to exercise this option.

Climbing is only a problem when you put pressure on the cyst. If it were in a less prominent position, it would not be an issue at all. Usually they go away, but the timeline is largely unknown; they can sit there for years, or maybe just months.

My advice would be to get so strong you can hang onto holds that don’t put pressure on it. The stronger you are, the smaller a jug actually becomes. Bouldering, because it involves smaller holds, is often less aggravating. When you have a jug, hold it so that there is no pressure on the cyst. This may not be the best formula for recovery, but there is no evidence that rest is any better. They come, they go and God only knows why.

On that note, the Bible and all its variations have been used as a manifesto of carnage for centuries. Nothing much has changed recently, though in addition to wreaking havoc on the wide variety of disbelievers, you can also use a heavy book to bludgeon, not metaphorically in this instance, your cyst to smithereens. It’s a miracle! The good lord, whatever his name, works in mysterious ways and irony is one of his strong points.

Hitting and breaking your cyst will be cheaper and more effective than anything. This is usually reserved for cysts on the back of your wrist that are more accessible. I am not convinced yours will be an easy target. A few patients have asked me to do it, but my insurance company says blunt trauma is not covered in my policy. Go figure.

Other than surgery or waiting and watching, acupuncture might work. I have seen great results for conditions like trigger finger, which is a similar type of pathology. You would need to speak to an acupuncturist about this.

Drop me a message on the forum at rockandice.com and let me know what you decide and how you get on.

Osteopath by trade, charismatic bondage queen by night, Dr. J has helped many. For your chance to win an overuse injury, log on to the Ask Dr. J forum at rockandice.com.